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. 2019 Jan 31;4(1):e000194.
doi: 10.1136/tsaco-2018-000194. eCollection 2019.

Extended resuscitative endovascular balloon occlusion of the aorta (REBOA)-induced type 2 myocardial ischemia: a time-dependent penalty

Philip J Wasicek  1 , William A Teeter  1 , Shiming Yang  2 , Hector Banchs  3 , Samuel M Galvagno  2 , Peter Hu  2 , William B Gamble  1 , Melanie R Hoehn  1 , Thomas M Scalea  1 , Jonathan J Morrison  1
Affiliations

Extended resuscitative endovascular balloon occlusion of the aorta (REBOA)-induced type 2 myocardial ischemia: a time-dependent penalty

Philip J Wasicek et al. Trauma Surg Acute Care Open. .

Abstract

Background: Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) increases cardiac-afterload and is used for patients in hemorrhagic shock. The cardiac tolerance of prolonged afterload augmentation in this context is unknown. The aim of this study is to quantify cardiac injury, if any, following 2, 3 and 4 hours of REBOA.

Methods: Anesthetized swine (70-90 kg) underwent a 40% controlled hemorrhage, followed by supraceliac resuscitative endovascular balloon occlusion of the aorta (REBOA) for 2 (n=5), 3 (n=5), and 4 hours (n=5). High-fidelity arterial wave form data were collected, and signal processing techniques were used to extract key inflection points. The adjusted augmentation index (AIx@75; augmentation pressure/pulse pressure, normalized for heart rate) was derived for use as a measure of aortic compliance (higher ratio = less compliance). Endpoints consisted of electrocardiographic, biochemical, and histologic markers of myocardial injury/ischemia. Regression modeling was used to assess the trend against time.

Results: All animals tolerated instrumentation, hemorrhage, and REBOA. The mean (±SD) systolic blood pressure (mm Hg) increased from 65±11 to 212±39 (p<0.001) during REBOA. The AIx@75 was significantly higher during REBOA than baseline, hemorrhage, and resuscitation phases (p<0.05). A time-dependent rise in troponin (R2=0.95; p<0.001) and T-wave deflection (R2=0.64; p<0.001) was observed. The maximum mean troponin (ng/mL) occurred at 4 hours (14.6±15.4) and maximum T-wave deflection (mm) at 65 minutes (3.0±1.8). All animals demonstrated histologic evidence of acute injury with increasing degrees of cellular myocardial injury.

Discussion: Prolonged REBOA may result in type 2 myocardial ischemia, which is time-dependent. This has important implications for patients where prolonged REBOA may be considered beneficial, and strategies to mitigate this effect require further investigation.

Level of evidence: II.

Keywords: aortic occlusion; arterial waveform; cardiac; cardiac injury; hemorrhage; ischemia; reboa; resuscitative endovascular balloon occlusion of the aorta.

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Conflict of interest statement

Competing interests: JM is a clinical advisory board member for Prytime Medical.

Figures

Figure 1
Figure 1
Example of wave components of the arterial wave form and augmentation pressure. A and C demonstrate typical antegrade and reflective wave components. B and D demonstrate antegrade and reflective wave components with REBOA. AP, augmentation pressure; DBP, diastolic blood pressure; PP, pulse pressure; REBOA, resuscitative endovascular balloon occlusion of the aorta; SBP, systolic blood pressure.
Figure 2
Figure 2
Hemodynamic responses. AO, aortic occlusion; BD, balloon deflation; bpm, beats per minute; DBP, diastolic blood pressure; hem, hemorrhage protocol phase; HR, heart rate; resus, resuscitation phase; PA-S, systolic pulmonary artery pressure; PA-D, diastolic pulmonary artery pressure; SBP, systolic blood pressure.
Figure 3
Figure 3
Illustration of representative arterial wave forms at differing experimental time points (A–D): baseline, hemorrhage, aortic occlusion, and resuscitation, respectively. Adjusted augmentation index (AIx@75) throughout the experiment (E). AO, aortic occlusion; BD, balloon deflation; hem, hemorrhage; resus, resuscitation phase.
Figure 4
Figure 4
Demonstration of aggregate ECG T-wave deflection amplitude throughout the experiment (A). AO, aortic occlusion; BD, balloon deflation; hem, hemorrhage protocol phase; resus, resuscitation phase. Troponin trends for each group (B). H, hemorrhage; 2-HR-REBOA, 2 hours of occlusion; 3-HR-REBOA, 3 hours of occlusion; 4-HR-REBOA; 4 hours of occlusion; 60, 60 minutes after AO; 120, 120 minutes after AO; 180, 180 minutes after AO; 240, 240 minutes after AO; R30, 30 minutes after balloon deflation; E, 60 minutes after balloon deflation/euthanasia; REBOA, resuscitative endovascular balloon occlusion of the aorta.
Figure 5
Figure 5
Histologic incidence of myocardial eosinophilia (A). HE staining of myocardium showing subendocardial bands of ischemia (white circles, (B)). 2-HR-REBOA, 2 hours of occlusion; 3-HR-REBOA, 3 hours of occlusion; 4-HR-REBOA, 4 hours of occlusion; REBOA, resuscitative endovascular balloon occlusion of the aorta.
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